Provider Demographics
NPI:1104954577
Name:GRAY, DIANNE ELAINE (ARNP)
Entity type:Individual
Prefix:MRS
First Name:DIANNE
Middle Name:ELAINE
Last Name:GRAY
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:127 N JUNIPER ST
Mailing Address - Street 2:
Mailing Address - City:OMAK
Mailing Address - State:WA
Mailing Address - Zip Code:98841-9337
Mailing Address - Country:US
Mailing Address - Phone:509-422-6593
Mailing Address - Fax:509-422-0907
Practice Address - Street 1:127 N JUNIPER ST
Practice Address - Street 2:
Practice Address - City:OMAK
Practice Address - State:WA
Practice Address - Zip Code:98841-9337
Practice Address - Country:US
Practice Address - Phone:509-422-6593
Practice Address - Fax:509-422-0907
Is Sole Proprietor?:No
Enumeration Date:2007-02-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30004405363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7103203Medicaid